Over the past several years, the therapeutic landscape for patients with advanced, unresectable, or metastatic hepatocellular carcinoma has been transformed by the incorporation of checkpoint inhibitor immunotherapy into the treatment paradigm. Frontline systemic treatment options have expanded beyond anti-angiogenic tyrosine kinase inhibitors, such as sorafenib, to a combination of immunotherapy approaches, including atezolizumab plus bevacizumab and durvalumab plus tremelimumab, both of which have demonstrated superior response and survival to sorafenib. Additionally, combination treatments with checkpoint inhibitors and tyrosine kinase inhibitors have been investigated with variable success. In this review, we discuss these advances in systemic treatment with immunotherapy, with a focus on understanding both the underlying biology and mechanism of these strategies and their efficacy outcomes in clinical trials. We also review challenges in identifying predictive biomarkers of treatments and discuss future directions with novel immunotherapy targets.

Background: Percutaneous cholecystostomy (PCT) is an option for acute calculous cholecystitis in high-risk surgical patients. While PCT effectively manages acute episodes by providing source control, the management after PCT remains unclear. When feasible, subsequent interval cholecystectomy (IC) offers definitive disease resolution; however, clear guidelines for patient selection remain lacking. This study identifies factors that hinder the decision to proceed with IC, investigates whether IC after PCT is associated with improved survival, and assesses the incidence of subsequent biliary procedures after PCT. Methods: A retrospective cohort study was conducted using deidentified data from the TriNetX platform, encompassing over 100 million patients. Patients diagnosed with acute calculous cholecystitis who underwent PCT were identified. The primary outcome was the identification of factors associated with the failure to undergo IC after PCT. Secondary outcomes included assessing the hazard of death associated with IC, modeling IC as a time-varying covariate. Additionally, biliary interventions following PCT were quantified. Results: Among 419,102 patients with acute calculous cholecystitis, 8,483 (2.0%) underwent PCT. Of these, 43.0% subsequently underwent IC within one year. Patients with chronic ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, ascites, diabetes, and concurrent diagnosis of septic shock were less likely to undergo IC. Additionally, 40.9% of patients required at least one additional biliary intervention within one year following PCT. Conclusion: More than half of patients do not undergo IC after PCT. Patients with comorbidities such as chronic ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, ascites, diabetes, and concurrent diagnosis of septic shock are associated with failure to undergo IC. Moreover, patients who undergo PCT frequently require additional biliary interventions. This highlights the need for improved patient selection, structured follow-up, and optimization strategies to facilitate IC when feasible. A multidisciplinary approach is crucial for managing comorbidities, increasing surgical eligibility, and ultimately improving outcomes for patients undergoing PCT for acute calculous cholecystitis. Graphical

Small-bore feeding tubes (SBFT) in vulnerable patients carry a risk of iatrogenic pneumothorax by misplacement into the lung. This institution noted a series of iatrogenic pneumothoraxes caused by the placement of these devices. A resident-led, multidisciplinary team developed a hospital guideline through a consensus-driven process. The guideline mandated SBFT placement by approved “super-users” via the CORTRAK Enteral Access System or via non-CORTRAK Methods, including the 2-step X-ray Method, fluoroscopy, or direct visualization techniques. A “super-user” Program for the CORTRAK Enteral Access System was developed to assure competency and consistency. With the development of the guideline and “super-user” program, the authors observed a decrease in the number of SBFT-related iatrogenic pneumothoraxes. Following a brief period of adoption, the three-hospital organization has had no SBFT-related iatrogenic pneumothoraxes. This project demonstrates the effectiveness of developing a resident-driven, evidence-based hospital guideline for the safe passage of SBFTs.

Purpose: Ventral hernia (VH) management has progressed beyond simply physical repair of the defect. It now involves a strategy that purposefully restores abdominal core function and prevents future complications. This study investigates the association between ventral hernia repair (VHR) and functional disorders related to the abdominal core in addition to bowel obstruction, opioid misuse, and physical therapy utilization. Methods: This retrospective cohort study used administrative codes from the TriNetX database. The outcomes of interest were spine and pelvic floor dysfunction, constipation, incontinence, genital prolapse, bowel obstruction, opioid misuse, and physical therapy utilization. Results: A total of 587 384 patients were identified with diagnosis of VH. Of those, 81 830 (13.9%) underwent surgical repair. Surgery was associated with a significant reduction in the hazard for bowel obstruction (HR 0.65, 95% CI [0.63, 0.67]). There were no association between surgery and the hazard of opioid misuse (0.97, [0.93, 1.01]). The hazard ratios associated with surgery were 1.05 (1.02, 1.07) for spine and pelvic dysfunction, 1.03 (0.99, 1.05) for constipation, 0.97 (0.93, 1.01) for incontinence, and 0.88 (0.72, 1.07) for genital prolapse. The hazard ratio for physical therapy utilization after surgery was 1.76 (1.73, 1.80). Conclusions: VHR is associated with reduction in the hazard of bowel obstruction, while having no significant effect on opioid misuse. Additionally, surgical patients had a higher utilization of physical therapy. While surgical management was not associated with a reduction in the hazard of functional disorders, further research is warranted to better understand these relationships.